Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Wednesday, September 12, 2007

I apologize in advance to any of you who have any of the following diseases.

We had a comment in a recent post about Darwinian selection. I been saying for 30+ yrs that medicine is, by itself anti-darwinian. Think about it. How long would a juvenille onset diabetic live 50 or 60 years ago? Now they live and reproduce until they go on dialysis and even then they still reproduce! Same with sickle cell, hemophilia, 24 wk preemies, putting non-compliant hypertensives on dialysis at 30 yrs old, and we could go on and on..And the genes go on and on. And we get to pay for it all!

And of course, we as doctors, must treat them to the n'th degree. Hell, when I started practice a 24-weeker was called a miscarriage! What kind of quality of life do those babies have? We're just now finding out how those hundreds of thousands of dollars just lead to more hundreds of thousands of $$ keeping them alive in their wheelchairs and feeding tubes, etc...

We are not supposed to make "value or social" judgements. Who better than us to make those decisions? I'm tired of treating that 20 yr old in DKA for the 29'th time who smokes and does drugs(other than his insulin, of course). Sorry if I hurt anyone's feelings, but there are some things the Europeans do better than us!

30 comments:

I'm not a Doctor, just a burned out Social Worker. I made a similar argument in an Ethics class as an Undergrad 20+ years ago. When we were discussing our topics in class, I was called a "heartless Bitch" a "cold- hearted, bottom-line thinker" and various and sundry other less insulting appelations by classmates. However, I made an "A" on my paper for making a good case that instead of spending hundreds of thousands of dollars on preemies who were going to wind up as severely "challenged" children needing constant care and supervision, and thus more hundreds of thoused, if not millions of dollars in health-care cost thoughout their short lifespans, that we allow Nature to take it's course from the time of their births. Then the money that would have been spent on ultimately fruitless care for a NON-productive member of society, could be spent, instead, on child wellness programs such as immunizations, nutrition, maternal health, etc, etc. Just my 2 cents worth.

sorry for the repeat but folks, we are really not anti-darwinian in most of what we do. according to darwin the most 'fit' are, by definition, those beings who succeed in passing on their genetic material to the next generations. with the notable exception of the preemies you mention, most of the folks we care for in the ED have reproduced many times so what we do is simply a waste of money and not 'anti-darwinian'.

along these lines, what are we to do when, the inevitable march of technology and medical science allows us to push the age of viability back to 16weeks? 12 weeks? conception?

Appreciate your comment, but eyesight is not quite the same thing. With my glasses I can still be a productive citizen, it won't kill me, and I'm not costing the tax payer anything(at least I don't think I am!)If I don't improve my vision, I can still be a productive citizen in the same thing I do now. Like Ben Franklin, I'd just use a magnifying glass while sewing you up and I think he lived a pretty long time! (Maybe I couldn't be an NFL receiver or something similar)

My mom was told in 1985 that with my Type 1 diabetes my life expectancy would be 20 years less than other children my age (pretty significant, putting me on death's door around age 55 or 60), and I've been trying to prove the pediatrician wrong ever since.

Luckily, I have the crap autoimmune genes but I also have the efficient brain genes so I can reason my way out of killing myself in stupid ways.

I don't feel that passing on the crap autoimmune genes, whether or not my son gets diabetes, did much overall ill on society. Sorry. A lot of these young adult diabetics wise up after a few years and stop being idiots. You can only hope they do so before the kidney damage was done.

I am mainly tired of caring for children I didn't conceive. In the past 2 weeks I have seen a 16 year old with her three kids in tow, and a 20 year old G7P5. I'm all for individual responsibility and rights, but when someone reaches in my pocket to pay for someone else's irresponsibility, IUDs and forced sterilization come to mind.

First of all, I'm very offended: there is NOTHING the Europeans do better than us.

Second: Darwinism will only apply to those diseases that do not allow one to get to reproductive age - diabetes, hypertension, sickle cell, hemophilia etc... do NOT fall in this category.

So... let's restrict the discussion to keeping alive 24 weekers and the like. This type of discussion has vexed philosophers forever. Peter Singer, Professor of Bioethics at Princeton University, has made the argument that severely disabled infants (e.g. anencephalics) can be euthanized and it is morally correct to do so.

As a Darwinian-athiest-utilitarian I'm all for it. I also can respect those who believe otherwise - that is, unless you disagree with me, because I am always right.

here ETOTHEIPI and i part company. the argument boiled down has been hashed-out a million times and it centers on the existence of God and the uniqueness of the human soul. friends may agree to disagree about such things.

Darwinian evolution implies that there is some level of competition or evolutionary pressure, if you will. Welfare, social security and civil society have mostly removed any such pressure to a much greater degree than medicine has.

To make things seem even better, most of the intelligent/fit /evolutionarily favorable individuals aren't reproducing at the same rate as the rest of the population.

My niece, 16 years old, was diagnosed with Juvenille Diabetes, IDDM, or Type I Diabetes (whatever you'd like to call it) when she was 8 years old. Luckily, both of her parents are nurses and understood the "severity" of diabetes as opposed to those who think, "it is only diabetes, it could be cancer."

At 16 years old, my niece has a complete understanding of her diabetes, probably better than most nurses and doctors. She has an insulin pump that she is able to regulate for basal rates during school, out of school, on the weekends, and during her hormonal peeks. She is able to bolus herself depending on the carbohydrate and fat intake of her meals and whether or not that bolus needs to be given now, over 30 minutes or over 60 minutes. She plays soccer and swims and manages to control her diabetes then as well. She knows her symptoms that signal her highs and lows. Her average Hgb A1C is 5.9.

At the age of 16, her worries should be what she's wearing to the prom or on a date; but instead her major concern is what her career choice should be that will enable her to care for her health throughout her life span.

She's been refused the ability to ride on rides at major amusement parks because she was unable to remove her "beeper," despite having to educate most of the operators that what she wore was not a beeper but a lifeline. Still, they refused.

This girl, has never been in DKA, even at diagnosis. Her attention to her disease should be applauded. What is a shame is that most of us in the ER only see the ones that do not take care of themselves. There are many out there that do.

Hello,I agree with you to a point. I was born at 20 weeks, 35 years ago. I was told, the doctors told my Parents to make plans. They did, God and I fooled them all.My childhood was guarded, as I was blind in one eye. BUT I know I am a exception to the rule also.I went on to be a Paramedic, and now getting ready to Graduate RN school. I did not have the money to go to be a MD. I agree with you on raising others children, or seeing folks for the 4,5,6 time with more G8P7, it made me want to scream.But where do we draw the line? Do we set a age for those who are "too old" to be put down like dogs too, I mean it is only fair? Thanks to modern medicine they are living forever too with feeding tubes, trachs, and whatnot. With or without bad genes.

All I can say is I am one of the few and lucky ones I guess and that I can say and question," Was the money that was spent on "me" years ago worth it, to my parents, yes. To me I often question."Either way I have cheated death twice, as a adult and as a baby and I am here for a reason. LOL, and I guess to bitch about those who take stuff for granted,cause they have the magic "red card". Off to study guys but you all have great points I stand with for the most part.MedicP.S. sorry about the ramble........

Wow… Darwin aside, this post has the tone of coming from a genetic supremacist! Perfect genes are fine, but variations in the genetic code make an interesting life for all of us.

Being a type 1 diabetic for 13 years, I am very thankful for ED doctors who treat DKA patients (as I’m sure that I will eventually have that unfortunate mishap) and as a medical student, my diabetes has driven me to pursue aspects of life that most people cannot accomplish... even with perfect genes! I do not do drugs but I drink, sometimes excessively, and although I am sometimes irresponsible with my decisions regarding my disease, my quality of life is fantastic and will continue to be so until I die. I will save lives as a physician and I will continuing to travel around the world catering to less fortunate people everywhere, all because some Darwinian ED doctor could find enough energy to treat my lowly DKA self, type 1 diabetes and all!

My point is… just because your patient is a 20 diabetic with 29 episodes of DKA, or a 16 year old mother of 3, saving that life you consider to be a genetic mishap in the human genome could change the world for many more people than you think. Just as man will evolve, so will medicine, which will allow for many more human advances, ultimately contributed, in part, by those people with weaker genetic codes!

Despite the fact that I disagree with your post in general, you make some interesting points. I have type 1 diabetes and acknowledge I'd be dead without insulin. But I also have asthma and have had an attack that I suspect would have killed me without the invention of albuterol. So how many people should be eliminated from the gene pool because they have conditions that would have killed them without medical inventions?

Child birth also used to kill people. Maybe no one should reproduce!

I guess few people argue that increasing life spans is a bad thing.

For the record, I've also never been in DKA. My last a1c was 5.5. After spending 8 weeks working on a renal floor I hope to God I never need dialysis.

This post reminds me of a joke my dad says to mock out my dumb dog, "Survival of the fittest- or those taken care of by a bigger specious." Just a reminder that many things in modern society buck darwin.

The more genes there are in the gene pool the better. Any one person could carry a gene that would provide resistance to a worldwide plague even if that person had a negative condition. There are plenty of instances where normally negative conditions can be positive in other circumstances. One example is Sickle-cell disease and malaria.

I realize that this original post has been on the web for quite a while so I am pretty late in getting in on a comment. But I truly enjoy the honesty of this site and the excellent exchange of ideas and knowledge, which I may say is way above my level. I am a nurse - and a mere lpn - at that so I don't even consider myself a medical profressional in knowledge base or experience.

But one thing I do specialize in life is attempting to be a follower of Jesus Christ. Everything I read or see or hear or consider, I try to filter it through God's view....and then attempt to line my view up to His standard.

So, Darwin and his teachings and his followers are simply ignorant to truth, because he doesn't take into fact the most important influence in life or death...God Himself. A world without God would be non-existent...since God Himself is the only self-existent one.

So all the babble about the survival of the fittest is mute! Every single part of our body was Created by the Creator that was much more knowledgeable and foreknowing than anyone who will ever ponder these ideas.

I love science (and medicine of course included) because you can't get far into a discussion about any topic without getting to the fact that all creation (including humans) are vastly more complicated and mindboggling to understand. Often it is easier to delight and marvel at our intricate design than to pretend to understand how it works.

So back to the orginal post, I totally agree that medicine is absolutely anti-darwinism....and anyone with a thinking true scientific mind would agree.

The real problem is that somewhere, someone stepped over the line of reasonable medical care and attempted to be a god...they attempted to control the point of a person's life and/or death. And this was all possible because we live in a welfare state mentality....medical research experiments...which are often what life saving attemps against all logic, known medical experience and knowledge, are being allowed, even forced to some degree. The only difference is research if funded. Hypothesis are carefully prepared. And careful records, including fiscal responsibility are taken.

When the taxpayer or private insurance (thus all paying insurance) or hospital organizations have to pay for these life saving feats of chance, there is no accountability...and no carefully research, conclusions and repeatable outcomes.

Doctors should be in the position to help families understand that there is no known medical course to take to extend life. At this point God should be given the opportunity to intervene, with one of His incredible miracles or His loving mercy to bring the precious soul home to Him.

Where we go so wrong today...is that we leave God and His infinite wisdom and power out of so many situations that are really only His call to make in the first place.

anyone read the book pro evo? According to the book people who live or make choices that go against evolution will not suceed in life. According to this theory evolution only goes in one direction, and anything anti evolution or life, will eventually fail, including poor choices such as drugs and murder. (e.g. though shall not kill, except in the instance someone is trying to kill innocent people, then you have every right to protect oneself, and loved ones, then it is justified. But no one should kill unless it is necessity to life or limb or it is only ok to take drugs to treat illness and help the body. It is said, the people who are pro evo, should try to help people who live anti-evo, because positive breeds positive, and negative breeds negative. I am a chrisitan and do believe in god as the creator of earth and all things living and not, but interesting application to life only by scientific means. In the end what will be will be; with or without our input.

my understanding of evolutionary theory is that over millions of years random mutations either provide a species with a competitive advantage or not.

the organisms with the deleterious or harmful mutations die and don't reproduce but organisms with helpful mutations reproduce and then the species becomes more able to survive.

accumulate enough mutations and speciation occurs. darwin himself would scratch his chin at humans acting to aid evolution beccause no one knows what that would mean. the process is random.

giraffes don't have long necks because they grew them longer to reach leaves in high trees, one malformed horse-like animal with a long neck was born due to a mutation and they lived to reproduce. so well in fact that their progeny outlived their shorter necked 'normal' cousins.

I guess by pro evolution, the book was actually quite weird and written by an unknown source that was distributed through out the US, at random free of charge, and received raved reviews from so called professional scientist, researchers, politicians and doctors throughout the world who chose to remain nameless. It basically described so called test theories and acts that had been proven for people to suceed in life, it spoke of energies, and physics, and scientific flow of life, and the creation of earth and the universe, and how we are all energy and what we give off, effects others. The book is careful not to mention religous beliefs, only similarites througout many sectors of religions and commanalities between all. The book talks about what has been proven socially, and and what has not. Like I was saying it was just kind of interesting to read, but also kind of weird. Me, I just choose to believe in my own faith, and that's enough for me.